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The patient has been diagnosed with a respiratory illness and reports shortness of breath. The nurse adjusts the temperature to facilitate the comfort of the patient. At which temperature range will the nurse set the thermostat?
- A. 60° to 64° F
- B. 65° to 75° F
- C. 15° to 17° C
- D. 25° to 28° C
Correct Answer: B
Rationale: The correct answer is B (65° to 75° F) because this temperature range is generally considered comfortable for most individuals, including those with respiratory illnesses experiencing shortness of breath. This range provides a balance between being not too cold to trigger discomfort or exacerbate respiratory symptoms and not too warm to cause overheating or breathing difficulties.
Choice A (60° to 64° F) is too cold and may worsen the patient's shortness of breath by causing them to shiver or feel uncomfortable. Choice C (15° to 17° C) is also too cold and may lead to discomfort and potential respiratory distress. Choice D (25° to 28° C) is too warm and can lead to overheating, exacerbating respiratory symptoms and making breathing more difficult.
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The nurse is providing information regarding safety and accidental poisoning to a grandparent who will be taking custody of a 1-year-old grandchild. Which comment by the grandparent will cause the nurse to intervene?
- A. The number for poison control is 800-222-1222.
- B. Never induce vomiting if my grandchild drinks bleach.
- C. I should call 911 if my grandchild loses consciousness.
- D. If my grandchild eats a plant
- E. I should provide syrup of ipecac.
Correct Answer: D
Rationale: Correct Answer: D - If my grandchild eats a plant.
Rationale:
- Eating some plants can be toxic to a child, so it is important to seek medical help immediately.
- Plants can cause serious harm and even be fatal if ingested.
- The other options emphasize important safety measures: calling poison control, not inducing vomiting, and seeking emergency help if the child loses consciousness.
- Providing syrup of ipecac is outdated and not recommended anymore due to potential risks.
- Calling 911 is crucial in emergencies, but the immediate concern with plants is to seek medical advice first.
The nurse enters the patient's room and notices a small fire in the headlight above the patient's bed. In which order will the nurse perform the steps, beginning with the first one?
- A. Pull the alarm.
- B. Remove the patient.
- C. Use the fire extinguisher.
- D. Close doors and windows.
Correct Answer: A
Rationale: The correct order is A: Pull the alarm. In case of a fire, alerting others is the first priority to ensure everyone's safety. This step will notify the fire department and initiate evacuation procedures. Removing the patient (B) should be done after sounding the alarm to prevent harm. Using the fire extinguisher (C) comes after ensuring the alarm is activated. Closing doors and windows (D) is important to contain the fire but should be done after alerting others and removing the patient.
A home health nurse is assessing a family's home after the birth of an infant. A toddler also lives in the home. Which finding will cause the nurse to follow up?
- A. Plastic grocery bags are neatly stored under the counter.
- B. Electric outlets are covered in all rooms.
- C. No bumper pads are in the crib.
- D. Crib slats are 5 cm apart.
Correct Answer: A
Rationale: The correct answer is A because storing plastic grocery bags under the counter poses a suffocation risk to the toddler. Toddlers could access the bags and potentially suffocate if they put a bag over their head. This finding requires immediate follow-up to ensure the safety of the child.
Choice B is incorrect because covering electric outlets is a safety measure for toddlers, not a cause for follow-up. Choice C is also incorrect because not having bumper pads in the crib is actually recommended for safe sleep practices. Choice D is incorrect as well since crib slats being 5 cm apart is within the safety guidelines.
The patient applies sequential compression devices after going to the bathroom. The nurse checks the patient's application of the devices and finds that they have been put on upside down. Which nursing diagnosis will the nurse add to the patient's plan of care?
- A. Risk for falls
- B. Deficient knowledge
- C. Risk for suffocation
- D. Impaired physical mobility
Correct Answer: B
Rationale: Correct Answer: B - Deficient knowledge
Rationale: The nurse's assessment indicates that the patient lacks the knowledge to properly apply the sequential compression devices, leading to them being put on upside down. This nursing diagnosis reflects the patient's need for education on device application to prevent potential harm.
Summary of other choices:
A: Risk for falls - Not directly related to the incorrect application of sequential compression devices.
C: Risk for suffocation - Not relevant to the situation described.
D: Impaired physical mobility - Incorrect application of devices does not necessarily indicate impaired physical mobility.
A nurse is inserting a urinary catheter. Which technique will the nurse use to prevent a procedure-related accident?
- A. Pathogenic asepsis
- B. Medical asepsis
- C. Surgical asepsis
- D. Clean asepsis
Correct Answer: C
Rationale: The correct answer is C: Surgical asepsis. This technique involves creating and maintaining a sterile field to prevent contamination during invasive procedures like catheter insertion. The nurse will use sterile gloves, drapes, and equipment to minimize the risk of infection. Pathogenic asepsis (A) focuses on removing or destroying pathogens but may not ensure sterility. Medical asepsis (B) aims to reduce the number of pathogens but does not achieve a sterile environment. Clean asepsis (D) involves cleanliness but not the level of sterility required for invasive procedures.